Migraineurs are particularly susceptible to rebound headaches, which can occur with frequent use of symptomatic medications including acetaminophen, aspirin, caffeine, NSAIDs with short half-lives (e.g., ibuprofen), butalbital, ergotamine, opiate agonists, and triptans. 37 Frequent use of symptomatic medications may also result in tolerance (the decreased effectiveness of the same dose of an analgesic, often leading to the use of higher doses to achieve the same degree of effectiveness) and in habituation and dependence (respectively, the psychological and physical need to repeatedly use drugs).

Rebound headache is a retrospective diagnosis made when headache frequency decreases after the patient stops or reduces the medication suspected of causing the headache. The best evidence is from a prospective study on caffeine-withdrawal headache in persons with low to moderate caffeine intake (the equivalent of about 2.5 cups of coffee daily). In this study, 50% of persons given placebo had a headache by day 2, compared with 6% of those given caffeine. 38 Withdrawal was also associated with nausea, depression, and flulike symptoms.

Because it would be unethical to conduct prospective studies on rebound headache from medication withdrawal, only limited information is available regarding the percentage of migraineurs who are susceptible to rebound, the dosage limits, and the time required for rebound to develop. Clinical experience suggests that headache rebound can occur with simple analgesics if three or more of these agents are used daily for more than 5 days a week; with triptans or combination analgesics containing barbiturates, sedatives, or caffeine used more than 3 days a week; and with opioids or ergotamine tartrate used more often than 2 days a week.

In the treatment of suspected rebound headache, the medications acetaminophen, aspirin, NSAIDs with short half-lives, and triptans can be stopped abruptly. Caffeine use should be tapered off, to avoid withdrawal symptoms. Opiates and butalbital should be tapered because of the risk of a serious withdrawal syndrome. If butalbital is abruptly discontinued, phenobarbital can be substituted to prevent withdrawal; the phenobarbital is tapered down from 60 mg to 15 mg at night over 1 week. 39 After medication withdrawal, the duration of rebound headaches from triptans is about 4 days and from other analgesics is about 9 days. 40 A migraine preventive medication can also be started, but it may not be effective when patients are overusing symptomatic medications.

Two outpatient transitional strategies have been suggested to reduce the headaches during the withdrawal period. One approach is the use of prednisone: 60 mg a day for 2 days, 40 mg for 2 days, and then 20 mg for 2 days. 41 Alternatively, the combination of tizanidine and an NSAID (e.g., piroxicam, rofecoxib, naproxen, sustained-release ketoprofen, or celecoxib) may be effective. 42 Inpatient treatment is the same as for chronic daily headaches.

This is one section of a chapter about headache treatments published by WebMD Scientific American Medicine for doctors. For the full version, including tables and charts, click on "Headache" from WebMD Scientific American Medicine.


References
The author is a consultant or a member of the speakers' bureaus of GlaxoSmithKline, AstraZeneca, Merck & Co., Inc., Pharmacia & Upjohn, Pfizer, Inc., Elan Corp., and Ortho-McNeil Pharmaceutical, Inc.

Click here for all references for this article.

Originally published April 2003.

2003 WebMD Inc. All rights reserved.

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